What's New

11/18/2024: The Office of Management and Budget (OMB) has renewed the Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146).  Plan Sponsors must use the current notice until December 31, 2024, and are required to use the new notice beginning January 1, 2025. 

The updated Part D denial notices, including Spanish, Chinese, Korean, and Vietnamese translations, are available in the "Downloads" section below. 

Additionally, the model notices have been updated and are available for immediate use (see Model Notices below for instructions on the dismissal model notices).  Both Microsoft Word and PDF formats are available in the Downloads section at the bottom of this page.

This page includes a number of notices and other documents for plan sponsors. Questions regarding any of the Part D notices can be submitted through this link: https://appeals.lmi.org/

Standardized Notices

CMS has developed the following standardized notices to be used by plan sponsors:

• Medicare Prescription Drug Coverage and Your Rights ("Pharmacy Notice")
• Notice of Denial of Medicare Part D Prescription Drug Coverage

Medicare Prescription Drug Coverage and Your Rights (CMS-10147)

The standardized notice Medicare Prescription Drug Coverage and Your Rights (CMS-10147) ("pharmacy notice") and form instructions are available in the "Downloads" section below.).  

Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146)

The Notice of Denial of Medicare Part D Prescription Drug Coverage, both in English and Spanish, which includes the corresponding instructions is available in the "Downloads" section below.

Effective 11/18/2024: The Office of Management and Budget (OMB) has renewed the Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146).  Plan Sponsors must use the current notice until December 31, 2024, and are required to use the new notice beginning January 1, 2025.  The zip files containing the new notices are marked with an expiration date of 11/30/2027. CMS has translated this updated notice into Spanish, Korean, Chinese and Vietnamese. All translated version of the notice are available in the download section.

Model Notices

CMS model notices contain all of the elements CMS requires for proper notification to enrollees or prescribers, if applicable. Plan sponsors may modify the model notices and submit them to the appropriate CMS regional office for review and approval. Plan sponsors may use these notices at their discretion.

NOTE REGARDING MEDICARE NOTICES WITH QIO INFORMATION:

Providers, suppliers, Medicare Advantage Organizations and Prescription Drug Plans should make certain that their Medicare notices include the correct Quality Improvement Organization (QIO) contact information.  Please see  www.qioprogram.org  for QIO details.

Effective 11/18/2024: The following model notices have been updated and are available for immediate use.  Both Microsoft Word and PDF formats are available in the Downloads section at the bottom of this page.

• Notice of Right to an Expedited Grievance
• Notice of Case Status
• Request for Additional Information
• Notice of Inquiry 
• DMP Model Redetermination Notice
• Model Redetermination Notice 
• Denial of Medicare Drug Coverage
• Medicare Drug Coverage Denial Request for Redetermination

The following notices have been updated to incorporate the regulatory change in the timeframe to submit an appeal from 60 calendar days to 65 days calendar days from the date of the notice. These model notices are available for use beginning 01/01/2025. Medicare health plans should continue to use the current model notices through December 31, 2024.

• Notice of Dismissal of Coverage Request
• Notice of Dismissal of Appeal Request

CMS has published additional guidance through the Health Plan Management System (HPMS) that clarifies a number of issues related to Part D grievances, coverage determinations, and appeals (see "HPMS Guidance History" in the "Related Links" section below).